Canadian Society

of Palliative Care Physicians Advanced Learning in Palliative Medicine

Calgary, Alberta

May 24, 2019

Leonie Herx, MD, PhD, CCFP (PC)

Margaret Cottle, MD, CCFP (PC)

Moral Distress, Moral Residue

& Moral Courage

Disclosures:

Dr. Herx has no conflicts of interest

Dr. Cottle is on the boards of two charities

but receives no financial or other benefits

Objectives:

1. Review definitions of moral distress

(MD), moral residue (MR), crescendo effect

& moral courage

2. Review these concepts using

a variety of approaches—including images

3. Discuss/share examples of MD & MR

in palliative care practice

4. Discuss tools & strategies for addressing

MR

Definitions:

Moral Distress:

pain or anguish resulting when we

know the right thing to do,

but are prevented from doing it.

May be prevented from doing the “right”

thing, or forced to do the “wrong” thing

Definitions:

Moral Residue:

follows moral distress; what remains

when we feel we have compromised

ourselves in a situation of moral

distress.

Definitions:

Crescendo Effect:

follows repeated situations

of moral distress;

may lead to a “breaking point”

Definitions:

Moral Courage:

Acting ethically in a situation of risk

Elements of Moral Distress:

A person …

*Is aware of a moral problem

*Acknowledges moral responsibility

*Makes a moral judgment about the correct

action

*Is unable to take the correct action or prevent

an incorrect action as a result of real

or perceived constraints

NB

Moral distress and its sequellae can

happen to any member of the

healthcare team,

in any part of medicine, and affects

not only individuals, but teams as well.

A series of images was presented

here:

1) Father holding onto his son dangling

from the chair lift

2) Child soldiers

3) Man in front of tank in Tiananmen

Square in 1989

4) Halifax family that lost their 7

children in the fire

Effects of Moral Distress:

Your suggestions….

Effects of Moral Distress:

*sense of powerlessness

*feelings of frustration and anger

*feeling belittled, unimportant, or unintelligent

*hesitance to speak openly about the situation

*feelings of shame and isolation

*job retention—worry or actual loss

*“horizontal” violence

*patient care gaps

*team dysfunction

HEC Forum

https://doi.org/10.1007/s10730-019-09372-w

Professionalism: An Archaeology

Tom Koch

HEC Forum

HealthCare Ethics Committee Forum:

An Interprofessional Journal on

Healthcare Institutions' Ethical and

Legal Issues

ISSN 0956-2737

DOI 10.1007/s10730-019-09372-w

Hjere is the excerpt from Dr. Koch’s article that we read…

“What some have called a “hidden curriculum” disavowing vocational goals in favor

of other priorities is a reported source of moral distress among medical students whose

vocational expectations are confounded by the realities of contemporary medicine in a

neoliberal environment (de Carvalho-Filho 2018 ). As a foundation medical student in

Great Britain reported, real patient engagement and the satisfaction that comes from

it is sometimes discouraged as “unprofessional” even when it has a clear therapeutic

rationale (Koch and Jones 2010 ).

Others have argued the distance between vocational values and practical constraints

on care contribute to drop-out rates among students and either “burn-out” or early

retirement among practitioners. The result is less “burn-out”—a kind of ennui—however,

than a moral injury implicated by some in the high rates of suicide among practicing

physicians since the 1990s (Talbot and Dean 2018 ). In the United States, physicians

are more likely to commit suicide than U.S. military veterans (28-40 versus 20.6 per

1000,000) (Anderson 2018 ). Compared to the general population, physicians are

nearly

twice as likely to commit suicide than their patients, 1.87 times higher than the average

American (Hoffman and Kunzmann 2018 ).”

Stories from the presenters to get you

thinking about your own situations…

Sharing and Discussion:

In groups of 2-3 people…

Share brief stories about a specific time you

have experienced moral distress

Identify the moral principle that you felt was

being threatened

We would be grateful to hear your insights

after the discussion time…

What might we do?

American Association of Critical

Care Nurses 4 A’s

ASK

AFFIRM

ASSESS

ACT

ASK: Review the definition and

symptoms of moral distress and ask

yourself whether what you are feeling

is moral distress. Are your colleagues

exhibiting signs of moral distress as

well?

AFFIRM: Affirm your feelings about the

issue. What aspect of your moral

integrity is being threatened? What role

could you (and should you) play?

ASSESS: Begin to put some facts

together. What is the source of your

moral distress? What do you think is

the “right” action and why is it so? What

is being done currently and why? Who

are the players in this situation? Are

you ready to act?

ACT: Create a plan for action and

implement it. Think about potential

pitfalls and strategies to get around

these pitfalls.

Strategies to reduce moral distress

(adapted from Hamric, Davis,&

Childress, 2006; Epstein & Hamric,

2009)

Cited in:

Epstein, E.G., Delgado, S., (Sept 30, 2010)

"Understanding and Addressing Moral Distress"

OJIN: The Online Journal of Issues in Nursing

Vol. 15, No. 3, Manuscript 1.

DOI: 10.3912/OJIN.Vol15No03Man01

Strategy:

Speak up

Implementation: Identify the problem, gather the facts,

and voice your opinion

Strategy:

Be deliberate

Implementation: Know who you need to speak with

and know what you need to speak about

Strategy:

Be accountable

Implementation: Sometimes, our actions are not quite right.

Be ready to accept the consequences,

should things not turn out the way you had

planned.

Strategy:

Build support networks

Implementation: Find colleagues who support you or who

support acting to address moral distress.

Speak with one authoritative voice.

Strategy:

Focus on changes

in the work environment

Implementation: Focusing on the work environment will be

more productive than focusing on an

individual patient. Remember, similar

problems tend to occur over and over. It’s

not usually the patient, but the system, that

needs changing.

Strategy:

Participate in moral distress education

Implementation: Attend forums and discussions about moral

distress. Learn all you can about it..

Strategy:

Make it interdisciplinary

Implementation: Many causes of moral distress are

interdisciplinary. No discipline alone can

change the work environment. Multiple

views and collaboration are needed to

improve a system, especially a complex

one, such as a hospital unit.

Strategy:

Find root causes

Implementation:

What are the common causes of moral

distress in your unit? Target those.

Strategy:

Develop policies

Implementation:

Develop policies to encourage open

discussion, interdisciplinary collaboration,

and the initiation of ethics consultations.

Strategy:

Design a workshop

Implementation:

Train staff to recognize moral distress,

identify barriers to change, and create a

plan for action.

We’re good at what we do and have

important input to offer

Continue important advocacy

as physicians and citizens 1 posted letter = 450 votes

educate/inform health authorities

& other “meso” levels

support each other

“Violence is what happens when we don’t know

what else to do with our suffering.”

“I think that axiom applies on every level of life.

When individuals don’t know what to do with their

suffering, they do violence to themselves or others near

them”

Parker Palmer: Educator and

Philosopher

These situations call for

thoughtful, careful attention:

Careful assessment

Careful preparation

Careful discussion

Careful analysis

Careful response

Your thoughts….

Also: Discuss together in your small groups:

what is one thing you could do in your own

setting

to address moral distress or moral residue,

and to enhance moral courage.

Thank you for your participation

Our emails:

Leonie.Herx@kingstonhsc.ca

mmcottle@mac.com